Healthcare Provider Details

I. General information

NPI: 1417376229
Provider Name (Legal Business Name): ANTHONY FREDERICK BUSHNELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 EAST ELM STE 100
CALDWELL ID
83605
US

IV. Provider business mailing address

3340 E GOLDTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-7415
  • Fax: 208-453-3307
Mailing address:
  • Phone: 208-459-7415
  • Fax: 208-453-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1135
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: